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HomeMy WebLinkAboutBld-20-004957 to vvse'.Jriiy l/ Y O erm 1IiFf v ✓V =-57 o(. - • . H lAmount G Ara M S[ '''. p:.o "'. p� Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATI9X sz TOWN OF YARMOUTH � Yarmouth Building Department , 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: AO—2 a Y'©rsC g„ S Ind, I K&rm OLt` / !4 o 6'-13 ASSESSOR'S INFORMATION: Map: /� Parcel: C ,3v(' OWNER:I/g—sG�I'tiir areal W Z2 icari-e /9a i J r J ®O - - 1 3� NAME PRESENT ADDRESS TEL. # CONTRACTOR✓'`B/a-' Sal n JC' `�t fa-K 2OO-22 /COr.Prz pfJkv d I fa f - 3 cc? eYs NAME MAILING ADDRESS TEL.# Residential 0 Commercial Est. Cost of Construction$ �,r� 'O� d C.7 Home Improvement Contractor Lic.# _/✓% 002 Construction Supervisor Lic.# '!✓6 i6,9 Workman's Compensation Insurance: (check one) ' I ❑ I am the homeowner ❑ I am the sole proprietor Lpf I have Worker's Compensation Insurance Insurance Company Name:d QLt/e/rt1 J Barr t O cyD Worker's Comp.Policy#/�'G Vo('/1Z0`(D WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares p Replacement windows: # Replacement doors: # Roofing: #of Squares if D (j )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like forlike Pool fencing *The debris will be disposed of at: Ka-r 1,44,0C4/1X ®/s'(s. v I 6 c— A. Location f Facility I declare under penalties of perjury that e statements herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial or revoc o cense and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: ©3/oJ '2, Owners Signature(or attachment) Date: 02/0, Approved By: -4; Date: 3� Building Official(or designee EMAIL ADDRESS:Q-G icemS/r c422) 7 d-! [/LLa t I. cixem Zoning District: Historical District: ❑ Yes No Flood Plain Zone: 2 Yes 2 No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes ❑ No ❑ Yes 2 No _e.� The Commonwealth of Massachusetts /, i l Department of Industrial Accidents \\77... 1 Congress Street, Suite 100 �, 02114- �•`''� Bostonwww,.MAmass.gov/dig2i017 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print Legibly Name (Business/Organization/Individual): AZ I 1 COP ti -6Ku c cit Ph t, L_Z C Address: 02 z deoC 5 e d,,,,J r City/State/Zip: e rtuou./ Jen 02,C-N Phone #: coP- 3)-/38g Are you an employer?Check the appropriate box: Type of project(required): I.1 I am a employer with 1 employees(full and/or part-time).* 7. E New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. ❑ Demolition 4.E I am a homeowner and will be hiring contractors to conduct all work on mY property. I will 10 ❑ Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.E Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 6.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 1-,.U/ROOf repairs These sub-contractors have employees and have workers'comp. insurance.: 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees. [No workers'comp. insurance required.] *Any applicant that checks box 411 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. +Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. �^ �j` Insurance Company Name: L Gt.5' �14 I t c-444 &h CQ Cc-D ec.P / 1-1- C Policy#or Self-ins. Lic. #: INC If 0141.2-,OLfe) f Expiration Date: 12/Lj/Zp 2 d ,� Job Site Address: 2D"Z 2 1/orfe f n i rd City/State/Zip:1V ii-r-440dg ti/f o c ' Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify unde the pains and penalties of perjury that the information provided above is true and correct. Signature: i Date: aJ/7 6/ ,2?- Phone#: sv - 3t -/3ec Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: LLC ALT CONSTRUCTION LLC Registration: 194702 22 HORSE POND RD Expiration: 02/28/2021 W.YARMOUTH, MA 02673 Update Address and Return Card. SCA 1 0 20M-05/17 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:LLC before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 194702 02/28/2021 1000 Washington Street-Suite 710 ALT CONSTRUCTION LW Boston,MA 02118 ALIAKSANDR TUROCU `,Q �J� Ve r•. 22 HORSE POND R0 W.YARMOUTH,MA 02673 Undersecretary N j,valid withol .BigTtature AC RE® MI CERTIFICATE OF LIABILITY INSURANCE DATE(MDD/YYYY) 3/6/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NE ACT Ashley Paiva Eastern Insurance Group LLC PHONE ): (800)333-7234 FAX No): 233 West Central St ADDREss:apaiva@easterninsurance.com INSURER(S)AFFORDING COVERAGE NAIC# Natick MA 01760 INSURER AArbella Protection Ins. Co. 41360 INSURED INSURER B Merchants Insurance Group 23329 ALT Construction LLC INsuRERCAtlantic Charter Insurance Gro 44326 22 Horse Pond Road INSURERD: INSURER E: W Yarmouth MA 02673 INSURERF: COVERAGES CERTIFICATE NUMBER:19-20 Master REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDD/YYYY) (MMIDO/YYYY) UMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE X OCCUR DAMAGEPREMMoccurrence)TO RENTED ISES(Ea occurrence) $ 100,000 9520049457 12/1/2019 12/1/2020 MED EXP(Any one person) $ 5,000 PERSONAL&ADVINJURY $ 1,000,000 GEM_AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY L I jE-, LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: Eon Benefits $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) $ -ANY AUTO BODILYINJURY(Perperson) $ 20,000 AU OS OWNED X SCHEDULED MCA1002609 6/2/2019 6/2/2020 BODILY INJURY(Per accident) $ 40,000 NON-OWNED PROPERTY DAMAGE $ X HIRED AUTOS AUTOS % AUTOS (Per accident) Uninsured motorist BI split limit $ 100,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N N/A E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER H)EXCLUDED? ACV01420401 12/4/2019 12/4/2020 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 C (Mandatory in NH) If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached K more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Display Purposes Only THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE R to Keyo, Kevin/APAI ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 r0n1d01\ owamn �Pm���� u�n�� . Board of Building Regulations and Standards ~~.~~ ' '------ ' -- HORSE WEST ,==MOU / ' Commissioner � \ ' . � ^ ' � ' ^ ^ � � � \ . ` _--_- . ^ � � ' � � ~